ARCHETYPE Inspection of a body fluid (openEHR-EHR-CLUSTER.inspection_body_fluid.v0)

Name: Inspection of a body fluid
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-CLUSTER.inspection_body_fluid.v0
Concept	Inspection of a body fluid
Description	Findings observed during the macroscopic inspection of an extracellular body fluid.
Use	Use to record a narrative description, structured details and clinical interpretation about findings observed during the inspection (including odour) of a body fluid. This archetype has been specifically designed to be used as the framework for recording details about examination of any body fluid and the context of the anatomical site or source of the body fluid will be carried in the archetypes in which it is nested, including but not limited to: - in the 'Examination findings' SLOT within many of the CLUSTER.exam family of archetypes and related inspection archetypes; - in the 'Physical properties' SLOT within the CLUSTER.specimen archetype; and - within other OBSERVATION or CLUSTER archetypes, where clinically appropriate. In order to record examination findings for: - specific types of fluids with unique attributes that need to be recorded, it is intended that a specific CLUSTER archetype for this purpose be nested within the 'Specific findings' SLOT. For example additional details only relevant to clear fluids will be recorded within a specific archetype for this purpose that will effectively extend this generic body fluid archetype; and - multicomponent body fluids such as amniotic fluid that may also contain obvious blood, meconium or pus, it is intended that one instance of this archetype be used to describe the amniotic fluid overall and additional instances of this same archetype will be nested with the 'Specific findings' SLOT to represent each of blood, meconium and pus. Body fluid is a liquid that originates from the human body, and this archetype is intended to support detailed description of: - normal physiological fluids; - physiological fluids that may be altered due to a pathological process; and - fluids generated as part of a pathological process within the body. Extracellular body fluid examples include, but are not limited to: - Amniotic fluid; - Blood and plasma; - Cerebrospinal fluid; - Discharge; - Urine; - Pus; - Saliva; - Sputum; - Synovial fluid; - Sweat; and - Vomitus. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. While this archetype will most likely be used in the context of a living subject, it is also appropriate to use in recording autopsy findings. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical description' data element.
Misuse	Not to be used to record the inspection of urine - use the specialisation CLUSTER.inspection_body_fluid-urine for this purpose. Not to be used to record the inspection of sputum - use the specialisation CLUSTER.inspection_body_fluid-sputum for this purpose. Not to be used to record the inspection of blood or blood clots, but only to record the presence of blood or blood clots within other fluids. Not to be used for recording measurements of fluid volume - use OBSERVATION archetypes for this purpose. For example: OBSERVATION.fluid_output. Not to be used to record details about a non-physiological fluid. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example: OBSERVATION.story and CLUSTER.symptom_sign. Not to be used to record the results of a urinalysis test - use OBSERVATION.urinalysis for this purpose. Not to be used to record the other details about a specimen for use in laboratory testing - use CLUSTER.specimen. Note: despite this exclusion, it is reasonable to use this archetype within the CLUSTER.specimen to describe physical properties about a body fluid as noted above. Not to be used to record the details about examination of faeces - use the CLUSTER.examination_faeces.
Purpose	To record the findings observed during the macroscopic inspection (including odour) of a body fluid.
References
Copyright	© openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-25
Other Details Language	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-25
OtherDetails Language Independent	{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Atomica Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=91ACD3D83FE57B07C01AAA6B8E46B872, build_uid=b0c76a3b-d9a9-4535-a610-32e3287980f3, revision=0.0.1-alpha}
Keywords	biofluid, amniotic, cerebrospinal, fluid, discharge, urine, pus, saliva, sputum, synovial, sweat, vomit, gastric, diarrhoea, mucous, mucus, spinal, bile, breast, milk, gastric, acid, semen, secretion, ascites, serous, intraocular, diasylate, synovial, bodily, pericardial, pleural
Lifecycle	in_development
UID	7ccea8db-8b05-4507-95bf-f019855f0ec8
Language used	en
Citeable Identifier	1013.1.2255
Revision Number	0.0.1-alpha
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Trust, Norway Evelyn Hovenga, EJSH Consulting, Australia Tom Jarl Jakobsen, Helse Bergen, Norway Lars Karlsen, DIPS ASA, Norway Dave Kilroy, Application Insight Ltd, United Kingdom Shinji Kobayashi, Kyoto University, Japan Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Siv Marie Lien, DIPS ASA, Norway Kelvin Lok, Stalis Ltd, United Kingdom Ole Kristian Losvik, Losol AS, Norway Mark McEvoy, SITS International, Sweden Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Lars Ivar Mehlum, Helse Bergen HF, Norway Colin Newell, OpusVL, United Kingdom Andrej Orel, Marand d.o.o., Slovenia Rob Organ, Yeovil District Hospital NHS Foundation Trust, United Kingdom Petra Palm, Region Östergötland, Sweden Mike Pargeter, Across Health Ltd, United Kingdom Martin Paulson, Sykehuset i Vestfold, Norway Rune Pedersen, Universitetssykehuset i Nord Norge, Norway John Pyle, self, United Kingdom Navin Ramachandran, NHS, United Kingdom Cecilia Revelj, Landstinget i Kalmar län, Sweden Ingela Sammeli, Landstinget i Värmland, Sweden Elin Tell, Region Ostergotland, Sweden John Tore Valand, Helse Bergen, Norway (openEHR Editor) Lina Öfverström, Region Östergötland, Sweden, originalLanguage=en, translators= Norwegian Bokmål: Kristian Berg, John Tore Valand, Helse Nord, Helse Vest , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], events=[], details=[], provider=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Fluid name, description=The name of the body fluid being examined., comment=Coding of the 'Fluid name' with a coding system is desirable, if available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Description, description=Narrative description about the fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Colour, description=The colour of the body fluid., comment=The intent of this data element is to record either a narrative description of the colour or to select one or more codes from a value set, appropriate to the body fluid, in a template., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022], code=at0022, itemType=ELEMENT, level=1, text=Blood, description=The qualitative amount of blood observed in the body fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0023::Absent [No blood is observed in the fluid.] at0024::Slight [There is a slight amount of blood observed.] at0025::Moderate [There is a moderate amount of blood observed.] at0026::Large [There is a large amount of blood observed.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0017], code=at0017, itemType=ELEMENT, level=1, text=Odour, description=The smell of the body fluid., comment=The 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itemType=SLOT, level=1, text=Specific findings, description=Additional structured details about the body fluid., comment=For example: inclusion of detailed CLUSTER archetypes to record details about specific fluids such as clear fluids; or inclusion of further CLUSTER.exam_body_fluid archetypes could describe components of substances such as required to describe a mixture of blood and meconium post childbirth., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.physical_properties.v0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the inspection findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the inspection findings, not captured in other fields., comment=null, 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topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1.., cardinalityText= (Cardinality: 1.., unordered), subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Fluid name, description=The name of the body fluid being examined., comment=Coding of the 'Fluid name' with a coding system is desirable, if available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Description, description=Narrative description about the fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Colour, description=The colour of the body fluid., comment=The intent of this data element is to record either a narrative description of the colour or to select one or more codes from a value set, appropriate to the body fluid, in a template., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022], code=at0022, itemType=ELEMENT, level=1, text=Blood, description=The qualitative amount of blood observed in the body fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0023::Absent [No blood is observed in the fluid.] at0024::Slight [There is a slight amount of blood observed.] at0025::Moderate [There is a moderate amount of blood observed.] at0026::Large [There is a large amount of blood observed.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0017], code=at0017, itemType=ELEMENT, level=1, text=Odour, description=The smell of the body fluid., comment=The intent of this data element is to record either a narrative description of the odour, or to code with a value set where appropriate in a template., 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